b. a. b. · Piles, Fissures and Fistula in anus Pilonidal sinus, Sinusitis and related disorders...

Prospectus ‘Arogya Sanjeevani Policy, Bharti AXA General Insurance Company’ UIN: BHAHLIP2014V011920 CIN : U66030KA2007PLC043362 Registered office address: 43, 1st floor, Hosto Centre, Opp. Imperial Hotel, Millers Road, Vasanth Nagar, Bangalore, Karnataka 560052. www.bharti-axagi.co.in. IRDAI Reg No: 139. Toll Free Number : 1800 103 2292 Email ID : [email protected]

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Arogya Sanjeevani Policy, Bharti AXA General Insurance Company

Prospectus

1. Eligibility Criteria for this Policy: Age Limits:

a. This Policy covers persons in the age group 91 days to 65 years. The maximum entry age is restricted to 65 years.

b. Children between 91 days and 25 years can be covered, provided either parent is getting insured under this Policy. However, if the child is above 18 years of age and is financially independent, he or she shall be ineligible for coverage in the subsequent renewals.

c. Age considered is the completed number of years as on last birthday. Members under the policy

a. This Policy can be issued to an individual and/or family. b. Family would include the proposer and one or more of the following members:

Legally wedded spouse

Parents & Parents in Law

Dependent Children (i.e. natural or legally adopted) between the ages 3 months to 25 years. If the child above 18 years of age is financially independent, he or she shall be ineligible for coverage in the subsequent renewals.

Policy Period This product will cover the insured for a maximum policy period of 1 year.

2. Covers and Benefits under this policy

The following are the covers and benefits provided under this policy. Note that some expenses

are restricted to a maximum limit (For example, Ambulance expenses is restricted to a

maximum of Rs.2, 000 per hospitalization). Please refer the policy wording for complete terms

and conditions.

Hospitalization

This would cover medical expenses incurred for hospitalization of the insured up to the sum

insured & cumulative bonus specified in the policy schedule. This would also include the

following, as per terms and conditions as specified in the policy wording:


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Room Rent, Boarding, Nursing Expenses as provided by the Hospital / Nursing Horne up to 2% of the sum insured subject to maximum of Rs.5000/-, per day,

Intensive Care Unit (ICU) / Intensive Cardiac Care Unit (ICCU) expenses up to 5% of sum insured subject to maximum of Rs.10, 000/- per day.

Surgeon, Anesthetist, Medical Practitioner, Consultants, Specialist Fees whether paid directly to the treating doctor / surgeon or to the hospital.

Expenses incurred on treatment of cataract subject to the sub limits.

Dental treatment, necessitated due to disease or injury

Plastic surgery necessitated due to disease or injury.

All the day care treatments

Expenses incurred on road Ambulance subject to a maximum of Rs.2000/- per hospitalization

Note:

Expenses of Hospitalization for a minimum period of’ 24 consecutive hours only shall be admissible. However, the time limit shall not apply in respect of Day Care Treatment.

In case of admission to a room /ICU /ICCU at rates exceeding the aforesaid limits, the reimbursement/payment of all other expenses incurred at the Hospital, with the exception of cost of medicines, shall be effected in the same proportion as the admissible rate per day bears to the actual rate per day of Room Rent/ICU/ICCU charges.

AYUSH Treatment

The Company shall indemnify medical expenses incurred for inpatient care treatment under Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy systems of medicines during each Policy Year up to the limit of sum insured as specified in the policy schedule in any AYUSH Hospital. Cataract Treatment The Company shall indemnify medical expenses incurred for treatment of Cataract, subject to a claim of 25% of Sum Insured or Rs.40, 000/-, whichever is lower, per each eye in one policy year. Pre Hospitalization This would cover pre-hospitalization medical expenses incurred, related to an admissible hospitalization requiring inpatient care, for a fixed period of 30 days prior to the date of admissible hospitalization covered under the policy. Post Hospitalization


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This would cover post-hospitalization medical expenses incurred, related to an admissible hospitalization requiring inpatient care, for a fixed period of 60 days from the date of discharge from the hospital, following an admissible hospitalization covered under the policy.

The following procedures will be covered (wherever medically indicated) either as an in-patient or as part of day care treatment in a hospital up to 50% of Sum Insured, specified in the policy schedule, during the policy period:

A. Uterine Artery Embolization and HIFU (High intensity focused ultrasound)

B. Balloon Sinuplasty

C. Deep Brain stimulation

D. Oral Chemotherapy

E. Immunotherapy- Monoclonal Antibody to be given as injection.

F. Intra Vitreal injections

G. Robotic surgeries

H. Stereotactic radio surgeries

I. Bronchical Thermoplasty

J. Vaporisation of the prostrate (Green laser treatment or holmium laser treatment)

K. IONM (Intra Operative Neuro Monitoring)

L. Stem Cell Therapy: Hematopoietic stern cells for bone marrow transplant for hematological conditions to be covered.

The expenses that are not covered in this policy are placed under List I of Annexure-A of the policy wording. The list of expenses that are to be subsumed into room charges, or procedure charges or costs of treatment are placed under List- II, List –III and List-IV of Annexure-A respectively of the policy wording.

3. Features under this Policy

The following are the features available under this policy.

Cumulative Bonus

Cumulative Bonus will be increased by 5% in respect of each claim free policy year (where no claims are reported), provided the policy is renewed with the company without a break subject to maximum of 50% of the sum insured under the current policy year. If a claim is made in any particular year, the cumulative bonus accrued shall be reduced at the same rate at which it has accrued. However, sum insured will be maintained and will not be


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reduced in the policy year.

For more details on this, please refer policy wordings.

Waiting Periods

The following waiting periods would be applicable under this policy:

For Pre-Existing Diseases:

Expenses related to the treatment of a pre-existing Disease (PED) and

its direct complications shall be excluded until the expiry of 48 months

of continuous coverage after the date of inception of the first policy with us.

In case of enhancement of sum insured the exclusion shall apply afresh

to the extent of sum insured increase.

If the Insured Person is continuously covered without any break as

defined under the portability norms of the extant IRDAI (Health

Insurance) Regulations then waiting period for the same would be

reduced to the extent of prior coverage.

Coverage under the policy after the expiry of 48 months for any pre-

existing disease is subject to the same being declared at the time of

application and accepted by us.

First Thirty Days Waiting Period

Expenses related to the treatment of any illness within 30 days from

the first policy commencement date shall be excluded except claims arising due to an accident, provided the same are covered.

This exclusion shall not, however, apply if the Insured Person has Continuous Coverage for more than twelve months.

The within referred waiting period is made applicable to the enhanced

sum insured in the event of’ granting higher sum insured subsequently.

Specific Waiting Period:

Expenses related to the treatment of the following listed conditions, surgeries/treatments shall be excluded until the expiry of’ 24/48

months of continuous coverage, as may be the case after the date of

inception of the first policy with the insurer. This exclusion shall not be applicable for claims arising due to an accident.

In case of enhancement of sum insured the exclusion shall apply afresh to the extent of sum insured increase.


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If any of the specified disease/procedure falls under the waiting period specified for pre-existing diseases, then the longer of the two waiting periods shall apply.

The waiting period for listed conditions shall apply even if contracted

after the policy or declared and accepted without a specific exclusion.

If the Insured Person is continuously covered without any break as

defined under the applicable norms on portability stipulated by IRDAI, then waiting period for the same would be reduced to the extent of

prior coverage.

24 Months waiting period

Benign ENT Disorders

Tonsillectomy

Adenoidectomy

Mastoidectomy

Tympanoplasty

Hysterectomy

All internal and external benign tumours, cysts, polyps of any kind,

including benign breast lumps

Benign prostate hypertrophy

Cataract and are related eye ailments

Gastric/ Duodenal Ulcer

Gout and Rheumatism

Hernia of all types

Hydrocele

Non Infective Arthritis

Piles, Fissures and Fistula in anus

Pilonidal sinus, Sinusitis and related disorders

Prolapse inter Vertebral Disc and Spinal Diseases unless arising from

accident

Calculi in urinary system, Gall Bladder and Bile Duct, excluding

malignancy

Varicose veins and varicose Ulcers

Internal Congenital Anomalies

48 Months Waiting Period

Treatment for Joint Replacement unless arising from accident

Age-related Osteoarthritis & Osteoporosis

4. Exclusions


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The Company shall not be liable to make any payment under the policy, in respect of’ any expenses incurred in connection with or in respect of’:

1. Investigation & Evaluation(Code- Excl04) a) Expenses related to any admission primarily for diagnostics and evaluation purposes. b) Any diagnostic expenses which are not related or not incidental to the current diagnosis and

treatment

2. Rest Cure, rehabilitation and respite care(Code- Excl05) a) Expenses related to any admission primarily for enforced bed rest and not for receiving

treatment. This also includes: i. Custodial care either at home or in a nursing facility for personal care such as help with

activities of daily living such as bathing, dressing, moving around either by skilled nurses or assistant or non-skilled persons.

ii. Any services for people who are terminally ill to address physical, social, emotional and spiritual needs.

3. Obesity/ Weight Control(Code- Excl06)

Expenses related to the surgical treatment of obesity that does not fulfil all the below conditions: 1) Surgery to be conducted is upon the advice of the Doctor 2) The surgery/Procedure conducted should be supported by clinical protocols 3) The member has to be 18 years of age or older and 4) Body Mass Index (BMI);

a) greater than or equal to 40 or b) greater than or equal to 35 in conjunction with any of the following severe co-

morbidities following failure of less invasive methods of weight loss: i. Obesity-related cardiomyopathy ii. Coronary heart disease iii. Severe Sleep Apnea iv. Uncontrolled Type2 Diabetes

4. Change-of-Gender treatments: (Code- Excl07) Expenses related to any treatment, including surgical management, to change characteristics of the body to those of the opposite sex.

5. Cosmetic or plastic Surgery: (Code- Excl08)


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Expenses for cosmetic or plastic surgery or any treatment to change appearance unless for reconstruction following an Accident, Burn(s) or Cancer or as part of medically necessary treatment to remove a direct and immediate health risk to the insured. For this to be considered a medical necessity, it must be certified by the attending Medical Practitioner. 6. Hazardous or Adventure sports: (Code- Excl09) Expenses related to any treatment necessitated due to participation as a professional in hazardous or adventure sports, including but not limited to, para-jumping, rock climbing, mountaineering, rafting, motor racing, horse racing or scuba diving, hand gliding, sky diving, deep-sea diving.

7. Breach of law: (Code- Excl10) Expenses for treatment directly arising from or consequent upon any Insured Person committing or attempting to commit a breach of law with criminal intent.

8. Excluded Providers: (Code-Excl11) Expenses incurred towards treatment in any hospital or by any Medical Practitioner or any other provider specifically excluded by the Insurer and disclosed in its website / notified to the policyholders are not admissible. However, in case of life threatening situations or following an accident, expenses up to the stage of stabilization are payable but not the complete claim.

9. Treatment for, Alcoholism, drug or substance abuse or any addictive condition and

consequences thereof.(Code- Excl12)

10. Treatments received in heath hydros, nature cure clinics, spas or similar establishments or private beds registered as a nursing home attached to such establishments or where admission is arranged wholly or partly for domestic reasons. (Code- Excl13)

11. Dietary supplements and substances that can be purchased without prescription, including

but not limited to Vitamins, minerals and organic substances unless prescribed by a medical practitioner as part of hospitalization claim or day care procedure (Code- Excl14)

12. Refractive Error:(Code- Excl15) Expenses related to the treatment for correction of eye sight due to refractive error less than 7.5 dioptres.

13. Unproven Treatments:(Code- Excl16) Expenses related to any unproven treatment, services and supplies for or in connection with any treatment. Unproven treatments are treatments, procedures or supplies that lack significant medical documentation to support their effectiveness.

14. Sterility and Infertility: (Code- Excl17)


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Expenses related to sterility and infertility. This includes: (i) Any type of contraception, sterilization

(ii) Assisted Reproduction services including artificial insemination and advanced

reproductive technologies such as IVF, ZIFT, GIFT, ICSI

(iii) Gestational Surrogacy

(iv) Reversal of sterilization

15. Maternity Expenses (Code - Excl 18): i. Medical treatment expenses traceable to childbirth (including complicated deliveries and

caesarean sections incurred during hospitalization) except ectopic pregnancy; ii. expenses towards miscarriage (unless due to an accident) and lawful medical termination of

pregnancy during the policy period.

16. War (whether declared or not) and war like occurrence or invasion, acts of foreign enemies, hostilities, civil war, rebellion, revolutions, insurrections, mutiny, military or usurped power, seizure, capture, arrest, restraints and detainment of all kinds.

17. Nuclear, chemical or biological attack or weapons, contributed to, caused by, resulting from

or from any other cause or event contributing concurrently or in any other sequence to the loss, claim or expense. For the purpose of this exclusion:

a) Nuclear attack or weapons means the use of any nuclear weapon or device or waste or

combustion of nuclear fuel or the emission, discharge, dispersal, release or escape of fissile/

fusion material emitting a level of radioactivity capable of causing any Illness, incapacitating

disablement or death.

b) Chemical attack or weapons means the emission, discharge, dispersal, release or escape

of any solid, liquid or gaseous chemical compound which, when suitably distributed, is capable

of causing any Illness, incapacitating disablement or death.

c) Biological attack or weapons means the emission, discharge, dispersal, release or escape

of any pathogenic (disease producing) micro-organisms and/or biologically produced toxins

(including genetically modified organisms and chemically synthesized toxins) which are

capable of causing any Illness, incapacitating disablement or death.

18. Any expenses incurred on Domiciliary Hospitalization and OPD treatment 19. Treatment taken outside the geographical limits of India

20. In respect of the existing diseases, disclosed by the insured and mentioned in the policy

schedule(based on insured’s consent), policyholder is not entitled to get the coverage for specified ICD codes.


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5. General Terms and Conditions

1. Disclosure of Information The Policy shall be void and all premium paid thereon shall be forfeited to the Company in the event of mis-representation, mis-description, or non-disclosure of any material fact.

2. Condition Precedent to Ad mission of Liability

The due observance and fulfilment of the terms and conditions of the policy, by the

insured person, shall be a condition precedent to any liability of the Company to make any

payment for claim(s) arising under the policy.

3. Material Change

The Insured shall notify the Company in writing of any material change in the risk in relation to the declaration made in the proposal form or medical examination report at each Renewal and the Company may, adjust the scope of cover and / or premium, if necessary, accordingly.

4. Records to be Maintained

The Insured Person shall keep an accurate record containing all relevant medical records

and shall allow the Company or its representatives to inspect such records. The

Policyholder or Insured Person shall furnish such information as the Company may require

for settlement of any claim under the Policy, within reasonable time limit and within the

time limit specified in the Policy

5. Complete Discharge

Any payment to the Insured Person or his/ her nominees or his/ her legal representative or

to the Hospital/Nursing Horne or Assignee, as the case may be, for any benefit under the

Policy shall in all cases be a full, valid and an effectual discharge towards payment of claim

by the Company to the extent of that amount for the particular claim.

6. Notice & Communication

i. Any notice, direction, instruction or any other communication related

to the Policy shall be made in writing.

ii. Such communication shall be sent to the address of the Company or through any other electronic modes specified in the policy

schedule.

iii. The Company shall communicate to the Insured at the address or through any other electronic mode mentioned in the schedule.


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7. Territorial Limit

All medical treatment for the purpose of this insurance will have to be taken in India only.

8. Multiple Policies 1. In case of multiple policies taken by an insured during a period from the same or one or

more insurers to indemnify treatment costs, the policyholder shall have the right to require a settlement of his/her claim in terms of any of his/her policies. In all such cases the insurer if chosen by the policy holder shall be obliged to settle the claim as long as the claim is within the limits of and according to the terms of the chosen policy.

2. Policyholder having multiple policies shall also have the right to prefer claims under this policy for the amounts disallowed under any other policy / policies, even if the sum insured is not exhausted. Then the Insurer(s) shall independently settle the claim subject to the terms and conditions of this policy.

3. If the amount to be claimed exceeds the sums insured under a single policy after, the Policyholder shall have the right to choose insurers from whom he/she wants to claim the balance amount.

4. Where an insured has policies from more than one insurer to cover the same risk on indemnity basis, the insured shall only be indemnified the hospitalization costs in accordance with the terms and conditions of the chosen policy.

9. Fraud If any claim made by the insured person, is in any respect fraudulent, or if any false

statement, or declaration is made or used in support thereof, or if any fraudulent means

or devices are used by the insured person or anyone acting on his/ her behalf to obtain

any benefit under this policy, all benefits under this policy shall be forfeited.

Any amount already paid against claims which are found fraudulent later under this Policy

shall be repaid by all person(s) named in the policy schedule, who shall be jointly and

severally liable for such repayment.

For the purpose of this clause, the expression "fraud" means any of the following acts

committed by the Insured Person or by his agent, with intent to deceive the insurer or to

induce the insurer to issue an insurance Policy:

a) the suggestion, as a fact of that which is not true and which the Insured

Person does not believe to be true;

b) the active concealment of a fact by the Insured Person having knowledge or belief of the fact;

c) any other act fitted to deceive; and

d) any such act or omission as the laws specifically declares to be fraudulent.


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The company shall not repudiate the policy on the ground of fraud, if the insured person/

beneficiary can prove that the misstatement was true to the best of his knowledge and

there was no deliberate intention to suppress the fact or that such mis-statement of or

suppression of material fact are within the knowledge of the insurer. Onus of disproving is

upon the policyholder, if alive, or beneficiaries.

10. Cancellation

a) The Insured may cancel this Policy by giving 15 days written notice, and in

such an event, the Company shall refund premium on short term rates for the unexpired Policy Period as per the rates detailed below.

Refund %

Refund of Premium (basis Policy Period)

Timing of Cancellation 1 Yr

Up to 30 days 75.00%

31 to 90 days 50.00%

3 to 6 months 25.00%

6 to 1.2 months 0.00%

Notwithstanding anything contained herein or otherwise, no refunds of premium shall be made in respect of Cancellation where, any claim has been admitted or has been lodged or any benefit has been availed by the Insured person under the Policy.

b) The Company may cancel the Policy at any time on grounds of mis-

representation, non-disclosure of material facts, fraud by the Insured Person,

by giving 15 days’ written notice. There would be no refund of premium on cancellation on grounds of mis-representation, non-disclosure of material

facts or fraud.

11. Automatic change in Coverage under the policy

The coverage for the Insured Person(s) shall automatically terminate: 1. In the case of his/ her (Insured Person) demise. However the cover shall continue for

the remaining Insured Persons till the end of Policy Period. The other insured persons may also apply to renew the policy. In case, the other insured person is minor, the policy shall be renewed only through any one of his/her natural guardian or guardian appointed by court. All relevant particulars in respect of such person (including his/her relationship with the insured person) must be submitted to the company along with the application. Provided no claim has been made, and termination takes place on account of death of the insured person, pro-rata refund of premium of the deceased insured person for the balance period of the policy will be effective.

2. Upon exhaustion of sum insured and cumulative bonus, for the policy year. However,


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the policy is subject to renewal on the due date as per the applicable terms and conditions.

12. Territorial Jurisdiction All disputes or differences or in relation to the interpretation of the terms, conditions, validity, construct, limitations and/or exclusions contained in the policy shall be determined by the Indian Court and according to Indian Law.

13. Arbitration

i. If any dispute or difference shall arise as to the quantum to be paid by the Policy, (liability being otherwise admitted) such difference shall

independently of all other questions, be referred to the decision of a sole arbitrator to be appointed in writing by the parties here to or if they cannot agree upon a single arbitrator within thirty days of any

party invoking arbitration, the same shall be referred to a panel of

three arbitrators, comprising two arbitrators, one to be appointed by each of the parties to the dispute/difference and the third arbitrator to

be appointed by such two arbitrators and arbitration shall be

conducted under and in accordance with the provisions of the

Arbitration and Conciliation Act 1996, as amended by Arbitration and

Conciliation (Amendment) Act, 2015 (No. 3 of 201 6).

ii. It is clearly agreed and understood that no difference or dispute shall

be preferable to arbitration as herein before provided, if the Company has disputed or not accepted liability under or in respect of the policy.

iii. It is hereby expressly stipulated and declared that it shall be a condition precedent to any right of action or suit upon the policy that award by

such arbitrator/arbitrators of the amount of expenses shall be first obtained.

14. Migration

The Insured Person will have the option to migrate the Policy to other health insurance

products/plans offered by the company as per extant Guidelines related to Migration. If

such person is presently covered and has been continuously covered without any lapses

under any health insurance product/plan offered by the company, as per Guidelines on

migration, the proposed Insured Person will get all the accrued continuity benefits in

waiting periods as per below:

i. The waiting periods specified in Section 6 shall be reduced by the

number of continuous preceding years of coverage of the Insured Person under the previous health insurance Policy.


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ii. Migration benefit will be offered to the extent of sums of previous sum insured and accrued bonus/multiplier benefit (as part of the base sum insured), migration benefit shall not apply to any other additional

increased Sum Insured.

For Detailed Guidelines on Migration, kindly refer the link:

https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_Layout.aspx?page=PageNo3986&flag=1


15. Portability The Insured Person will have the option to port the policy to other insurers as per extant

Guidelines related to portability. If such per son is presently covered and has been

continuously covered without any lapses under any health insurance plan with an Indian

General/Health insurer as per Guidelines on portability, the proposed Insured Person will

get all the accrued continuity benefits in waiting periods as under:

i. The waiting periods specified in Section 6 shall be reduced by the

number of continuous preceding years of coverage of the Insured Person under the previous health insurance Policy.

ii. Portability benefit will be offered to the extent of sum of previous sum

insured and accrued bonus (as part of the base sum insured), portability benefit shall not apply to any other additional increased Sum Insured.

For Detailed Guidelines on Portability, kindly refer the link:

https://www.irdai.gov.in/ADMINCMS/cms/frmGuidelines_Layout.aspx?page=PageNo

3986&flag=1


16. Renewal of Policy The policy shall ordinarily be renewable except on grounds of fraud, moral hazard,

misrepresentation by the insured person. The Company is not bound to give notice that it

is due for renewal.

i. Renewal shall not be denied on the ground that the insured had made

a claim or claims in the preceding policy years

ii. Request for renewal along with requisite premium shall be received by










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the Company before the end of the Policy Period.

iii. At the end of the Policy Period, the policy shall terminate and can be

renewed with in the Grace Period to maintain continuity of benefits without Break in Policy. Coverage is not available during the grace period.

iv. If not renewed with in Grace Period after due renewal date, the Policy

shall terminate.

17. Premium Payment in Installments

lf the insured person has opted for Payment of’ Premium on an installment basis i.e. Half

Yearly, Quarterly or Monthly, as mentioned in Your Policy Schedule/Certificate of

Insurance, the following Conditions shall apply (notwithstanding any terms contrary

elsewhere in the Pol icy):

i. Grace Period of 15 days would be given to pay the installment premium

due for the Policy.

ii. During such grace period, Coverage will not be available from the

installment premium payment due date till the date of’ receipt of premium by Company.

iii. The Benefits provided under — “Waiting Periods”, “Specific Waiting

Periods” Sections shall continue in the event of payment of premium within the stipulated grace Period.

iv. No interest will be charged if the installment premium is not paid on

due date.

v. In case of installment premium due not received within the grace

Period, the policy will get cancelled.

18. Possibility of Revision of Terms of the Policy Including the Premium Rates

The Company, with prior approval of IRDAI, may revise or modify the terms the policy

including the premium rates. The insured person shall be notified three months before

the changes are affected.

19. Free look period

The Free Look Period shall be applicable at the inception of the Policy and not on renewals or at the time of porting the policy.

The insured shall be allowed a period of fifteen days from date of receipt of the Policy to review the terms and conditions of the Policy, and to return the same if not acceptable.

If the insured has not made any claim during the Free Look Period, the insured shall be entitled to:

i. a refund of the premium paid less any expenses incurred by the


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Company on medical examination of the insured person and the stamp duty charges; or

ii. where the risk has already commenced and the option of return of the

Policy is exercised by the insured, a deduction towards the proportionate risk premium for period of cover or

iii. Where only a part of the insurance coverage has commenced, such

proportionate premium commensurate with the insurance coverage during such period;

20. Endorsements (Changes in Policy)

i. This policy constitutes the complete contract of insurance. This Policy

cannot be modified by anyone (including an insurance agent or broker)

except the company. Any change made by the company shall be evidenced by a written endorsement signed and stamped.

ii. The policy holder may be changed only at the time of renewal. The new

policyholder must be the legal heir/immediate family member. Such

change would be subject to acceptance by the company and payment of premium (if any). The renewed Policy shall be treated as having been

renewed without break.

The policyholder may be changed during the Policy Period only in case of his/her demise or

him/her moving out of India.

21. Change of Sum Insured

Sum insured can be changed (increased/ decreased) only at the time of renewal or at any

time, subject to underwriting by the Company. For any increase in SI, the waiting period

shall start afresh only for the enhanced portion of the sum insured.

22. Terms and conditions of the Policy

The terms and conditions contained herein and in the Policy Schedule shall be deemed to

form part of the Policy and shall be read together as one document.

23. Nomination:

The policyholder is required at the inception of the policy to make a nomination for the purpose of payment of claims under the policy in the event of death of the policyholder.

Any change of nomination shall be communicated to the company in writing and such change shall be effective only when an endorsement on the policy is made. For Claim settlement under reimbursement, the Company will pay the policyholder. In the event of

death of the policyholder, the Company will pay the nominee {as named in the Policy Schedule/Policy Certificate/Endorsement (if any)} and in case there is no subsisting


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nominee, to the legal heirs or legal representatives of the Policyholder whose discharge shall be treated as full and final discharge of its liability under the Policy.

24. Redressal of Grievance The Company is committed to extend the best possible services to its customers. However, If

Policyholder/Insured Person have a grievance that he/she wish us to redress, he/she may contact the

Company with the details of their grievance via:

•Website: www.bharti-axagi.co.in •Email: [email protected] •Phone: 022-61188888 •Courier: Any of the Company’s Branch office or corporate office Policyholder/Insured/ Insured Person may also approach the grievance cell at any of the Company’s

branches with the details of the grievance during working hours from Monday to Friday.

Escalation Level 1

In case the Policyholder/Insured/Insured Person has not got his/her grievances redressed through

one of the above methods (After 5 days of intimating of your complaint), Policyholder/ Insured/

Insured Person may contact the National Grievance Redressal Officer at :

Write to: Bharti AXA General Insurance, Spectrum Towers, 3rd floor, Malad Link Road, Malad (west), Mumbai- 400064 Call: 022-48815939 Email: [email protected]

Escalation Level 2

In case the Policyholder/ Insured/Insured Person has not got his/her grievances redressed through

any of the above methods (After 5 days of approaching National Grievance Redressal Officer),

Policyholder/ Insured/ Insured Person may contact the Chief Grievance Redressal Officer at:

Email: [email protected]

Escalation Level 3

In case the Policyholder/ Insured/Insured Person has not got his/her grievances redressed by the

Company within 14 days, or, If Policyholder/ Insured/Insured Person is not satisfied with Company’s

redressal of the grievance through one of the above methods, Policyholder/ Insured/ Insured Person

may approach the nearest Insurance Ombudsman for resolution of their grievance. The contact

details of Ombudsman offices are mentioned below. Policy holder may also obtain copy of IRDAI


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circular Ref No. F. No. IRDAI/Reg/8/145/2017, notification on Insurance Regulatory and Development

Authority (Protection of Policy holders’ interests) Regulations, 2017 from any of our offices.

Grievance of Senior Citizens:

In respect of Senior Citizens, the Company has established a separate channel to address the

grievances. Any concerns may be directly addressed to the Senior Citizen’s channel of the Company

for faster attention or speedy disposal of grievance, if any.

•Website: www.bharti-axagi.co.in •Email: [email protected] •Phone: 022-61188888 •Courier: Any of the Company’s Branch office or corporate office Insured/ Insured Person may also approach the grievance cell at any of the Company’s branches with

the details of the grievance during working hours from Monday to Friday.

Grievance Redressal Cell of the Consumer Affairs Department of IRDAI

The insurance company should resolve the complaint within a reasonable time. In case if it is not resolved within 15 days or if the Insured/Insured Person is unhappy with their resolution you can approach the Grievance Redressal Cell of the Consumer Affairs Department of IRDAI. •Website: igms.irda.gov.in •Email: [email protected] •Toll Free Number 155255 (or) 1800 4254 732 Insurance Ombudsman —The insured person may also approach the office of Insurance Ombudsman of the respective area/region for redressal of grievance. The contact details of the Insurance Ombudsman offices have been provided as Annexure-B of the policy wordings. No loading shall apply on renewals based on individual claims experience. Insurance is the subject matter of solicitation.

6. Sum Insured Under this policy The customer have the option to choose any sum insured from the following:

Rs.1, 00,000

Rs.1, 50,000

Rs.2, 00,000

Rs.2, 50,000

Rs.3, 00,000

Rs.3, 50,000

http://www.bharti-axagi.co.in/

mailto:[email protected]


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Rs.4, 00,000

Rs.4, 50,000

Rs.5, 00,000

The sum insured can be offered either on a floater basis or an individual basis.

List I- Items for which coverage is not available in the Policy SI No

Item

1 BABY FOOD 2 BABY UTILITIES CHARGES 3 BEAUTY SERVICES 4 BELTS/ BRACES 5 BUDS 6 COLD PACK/HOT PACK 7 CARRY BAGS 8 EMAIL / INTERNET CHARGES

9 FOOD CHARGES (OTHER THAN PATIENT's DIET PROVIDED BY HOSPITAL) 10 LEGGINGS

11 LAUNDRY CHARGES 12 MINERAL WATER 13 SANITARY PAD 14 TELEPHONE CHARGES 15 GUEST SERVICES 16 CREPE BANDAGE 17 DIAPER OF ANY TYPE 18 EYELET COLLAR 19 SLINGS 20 BLOOD GROUPING AND CROSS MATCHING OF DONORS SAMPLES 21 SERVICE CHARGES WHERE NURSING CHARGE ALSO CHARGED 22 Television Charges 23 SURCHARGES 24 ATTENDANT CHARGES 25 EXTRA DIET OF PATIENT (OTHER THAN THAT WHICH FORMS PART OF BED

CHARGE)

26 BIRTH CERTIFICATE 27 CERTIFICATE CHARGES 28 COURIER CHARGES 29 CONVEYANCE CHARGES 30 MEDICAL CERTIFICATE 31 MEDICAL RECORDS 32 PHOTOCOPIES CHARGES


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33 MORTUARY CHARGES 34 WALKING AIDS CHARGES 35 OXYGEN CYLINDER (FOR USAGE OUTSIDE THE HOSPITAL) 36 SPACER 37 SPIROMETRE 38 NEBULIZER KIT 39 STEAM INHALER 40 ARMSLING 41 THERMOMETER 42 CERVICAL COLLAR 43 SPLINT 44 DIABETIC FOOT WEAR 45 KNEE BRACES (LONG/ SHORT/ HINGED) 46 KNEE IMMOBILIZER/SHOULDER IMMOBILIZER 47 LUMBO SACRAL BELT 48 NIMBUS BED OR WATER OR AIR BED CHARGES

49 AMBULANCE COLLAR

50 AMBULANCE EQUIPMENT

51 ABDOMINAL BINDER

52 PRIVATE NURSES CHARGES- SPECIAL NURSING CHARGES

53 SUGAR FREE Tablets

54 CREAMS POWDERS LOTIONS (Toiletries are not payable, only prescribed medical pharmaceuticals payable)

55 ECG ELECTRODES

56 GLOVES

57 NEBULISATION KIT

58 ANY KIT WITH NO DETAILS MENTIONED [DELIVERY KIT, ORTHOKIT, RECOVERY KIT, ETC]

59 KIDNEY TRAY

60 MASK

61 OUNCE GLASS

62 OXYGEN MASK

63 PELVIC TRACTION BELT

64 PAN CAN

65 TROLLY COVER

66 UROMETER, URINE JUG

67 AMBULANCE

68 VASOFIX SAFETY


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List II- Items that are to be subsumed into Room Charges

SI No

Item

1 BABY CHARGES (UNLESS SPECIFIED/INDICATED) 2 HAND WASH 3 SHOE COVER 4 CAPS 5 CRADLE CHARGES 6 COMB 7 EAU-DE-COLOGNE / ROOM FRESHNERS 8 FOOT COVER 9 GOWN 10 SLIPPERS 11 TISSUE PAPER 12 TOOTH PASTE 13 TOOTH BRUSH 14 BED PAN 15 FACE MASK 16 FLEX I MASK 17 HAND HOLDER 18 SPUTUM CUP

19 DISINFECTANT LOTIONS 20 LUXURY TAX

21 HVAC 22 HOUSE KEEPING CHARGES 23 AIR CONDITIONER CHARGES 24 IM IV INJECTION CHARGES 25 CLEAN SHEET 26 BLANKETS/VARMER BLANKET 27 ADMISSION KIT

28 DIABETIC CHART CHARGES

29 DOCUMENTATION CHARGES / ADMINISTRATIVE EXPENSES

30 DISCHARGE PROCEDURE CHARGES

31 DAILY CHART CHARGES

32 ENTRANCE PASS / VISITORS PASS CHARGES

33 EXPENSES RELATED TO PRESCRIPTION ON DISCHARGE

34 FILE OPENING CHARGES

35 INCIDENTAL EXPENSES / MISC. CHARGES (NOT EXPLAINED)

36 PATIENT IDENTIFICATION BAND / NAME TAG

37 PULSEOXYMETER CHARGES


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List III — Items that are to be subsumed into Procedure Charges SI No.

Item

1 HAIR REMOVAL CREAM 2 DISPOSABLES RAZORS CHARGES (for site preparations) 3 EYE PAD 4 EYE SHEILD 5 CAMERA COVER 6 DVD, CD CHARGES 7 GAUSE SOFT 8 GAUZE 9 WARD AND THEATRE BOOKING CHARGES 10 ARTHROSCOPY AND ENDOSCOPY INSTRUMENTS 11 MICROSCOPE COVER

12 SURGICAL BLADES, HARMONICSCALPEL,SHAVER 13 SURGICAL DRILL 14 EYE KIT 15 EYE DRAPE

16 X-RAY FILM 17 BOYLES APPARATUS CHARGES 18 COTTON 19 COTTON BANDAGE 20 SURGICAL TAPE 21 APRON

22 TORNIQUET 23 ORTHOBUNDLE, GYNAEC BUNDLE

List IV — Items that are to be subsumed into costs of treatment SI No.

Item

1 ADMISSION/REGISTRATION CHARGES

2 HOSPITALISATION FOR EVALUATION/ DIAGNOSTIC PURPOSE

3 URINE CONTAINER

4 BLOOD RESERVATION CHARGES AND ANTE NATAL BOOKING CHARGES 5 BIPAP MACHINE

6 CPAP/ CAPD EQUIPMENTS

7 INFUSION PUMP— COST

8 HYDROGEN PEROXIDE\SPIRITS DISINFECTANTS ETC

9 NUTRITION PLANNING CHARGES - DIETICIAN CHARGES- DIET CHARGES

10 HIV KIT


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11 ANTISEPTIC MOUTHWASH

12 LOZENGES

13 MOUTH PAINT

14 VACCINATION CHARGES

15 ALCOHOL SWABES

16 SCRUB SOLUTION/STERILLIUM

17 Glucometer& Strips

18 URINE BAG

b. a. b. · Piles, Fissures and Fistula in anus Pilonidal sinus, Sinusitis and related disorders...

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Transcript of b. a. b. · Piles, Fissures and Fistula in anus Pilonidal sinus, Sinusitis and related disorders...